Certification Recommendation Request Form

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Certification Recommendation Request Form

Please complete this form and submit it if you are a student enrolled in the FINAL semester of a teacher education, school administrator program or school counselor program that leads to NYS Certification. Processing of your form by the Certification Officer will occur when your graduation date has posted to your transcript in Brockportal, there are no holds on your account, and required workshops are confirmed. Please do not submit multiple copies of this form as it will slow down processing time.

Today's Date Today's Date * / MM / DD YYYY
Name Name * First Middle Last
Birthdate Birthdate * / MM / DD YYYY
BANNER ID *
Phone Number Phone Number * - ### - ### ####
Email *
Degree Type *

Degree Type Bachelor of Science Bachelor of Arts Master of Science in Education Certificate of Advanced Study
Education Program *
Anticipated Month of Graduation *

Anticipated Month of Graduation January May August December
Anticipated Year of Graduation *
Release Authorization for Certification Recommendation:
I authorize the Office of Certification at The College at Brockport to disclose my Social Security number, date of birth, academic transcript, and any other information pertaining specifically to the certification requirements in New York State to the Office of Teaching Initiatives of the New York State Education Dept. (NYSED) for the purpose of endorsing my application for certification in New York State.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.